Population and International Health PIH 31 - Health Systems International 2

Prof Ruair Brugha Dept Epidemiology and Public Health Medicine

1. Explain and evaluate the main mechanisms for financing health services world-wide, especially
Health insurance, Social Insurance and Tax

2. List the stewardship roles of government 3. Provide criteria for evaluating national health systems performance using examples

Financing mechanisms (1)

1. Taxes (main mechanism in Ireland and Middle East):
tax levels based on residents ability to pay Government determines level of funds allocated to Health (in some countries funds can be ear-marked for Health)

2. * Social Health Insurance (Germany + Thailand +Malaysia?)

Everyone above an income threshold must pay a contribution based on income or ability to pay Contributions to the social insurance fund kept separate from government tax revenue Social insurance fund finances care for those who need it, which can be delivered by public or private providers Government policy in Ireland but will it happen??

1 and 2 aim are considered progressive, access to care based on need * See Thomas et al 2006 in Readings

Financing mechanisms (2)

3. *Private Health Insurance (Ireland, South Africa, USA)
Steps
a) Contract between an individual and an insurance company
Individual pays an annual fee (a premium) Insurance company undertakes to pay for care if s/he falls ill

b) Risk assessors (actuaries) assess risk that s/he will fall ill c) Company determines premium level based on risk assessment

Principle
Risk-sharing: the assumption that some people will not require treatment during the year who will subsidise those whose treatment will cost more than the level of premiums they paid

Problem

Risk-selection: insurance companies may choose not to insure

(discriminate against) those at higher risk major problem in U.S.

Health insurance: Problems

1. Risk averse: the assumption that sufficient numbers feel the need to take out insurance, even though there risks are low (however, young healthy people are tend not to be risk averse) 2. Affordability: the growing problem in Ireland. Many of those hit by economic recession feel they can no longer afford insurance and the healthy younger generation not taking out insurance 3. Adverse selection those most likely to fall ill and need health services are more likely to pay for it 4. People hide pre-existing conditions that might lead companies to not insure them or charge them higher premiums another form of information asymmetry 5. Moral hazard: once people are insured and incur no further costs, there is no disincentive to seeking care (therefore co-payments)

Health insurance in Ireland: a two tier system

Reasons people have private insurance ESRI 2001
1. Avoid large bills 2. Ensure quick (quicker) treatment 3. Ensure good (better?) treatment 4. Ensure consultant care 88% 85% 73% 59%

Two tier care?

non-insured (public) patients

1. Less likely to be cared for by a fully trained doctor (consultant) 2. Longer waiting lists (slower access to hospital) often leading to deterioration in health

Who benefits ..?

Financing mechanisms(3)

4. Health Maintenance Organisations (US) 5. Private medical savings (Singapore) 6. Out of pocket / fee for service (India and Africa)
Risks of catastrophic illness* In practice many countries use combinations of the above financing mechanisms, with different ones for different population subgroups Public Private mix in a country (% of doctors public and/or private) is both a consequence and a determinant of privatisation strong pressures in Ireland towards privatisation in the 2000s Choice of financing mechanism is fundamentally about ideology (see health care reform in USA) 46 million (15%) of US population have no insurance

Readings
Thomas S, Normand C. Smith S. Social Health Insurance: Options for Ireland . Trinity College Dublin. 2006 (esp pp 5-9)
http://www.adelaide.ie/cms/cms/uploads/files/full_report.pdf

Health Insurance http://en.wikipedia.org/wiki/Health_insurance

Health Insurance in the United States http://en.wikipedia.org/wiki/Health_insurance_in_the_United_States Health Maintenance Organisations http://en.wikipedia.org/wiki/Health_maintenance_organization Patient Protection and Affordable Care Act (PPACA),[1] commonly called the Affordable Care Act (ACA) or "Obamacare http://en.wikipedia.org/wiki/Obamacare

Government Stewardship: 6 functions

System design Policy formulation and setting strategic direction Performance assessment Information and monitoring Priority setting Technical and political dimensions Inter-sectoral action across govt departments Regulation and population protection
name 4 areas where governments regulate to protect health? Water, food, transport, pharmaceuticals
World Health Report 2000: Health Systems improving performance . Ch 6. How is the public interest protected? http://www.who.int/whr/2000/en/ Health Policy: vision for the future, Exercising intelligence, Strategies roles and resources (who should do what), Setting rules and ensuring compliance
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Health Equity
There are often differences across populations
in health status, presence of disease, or quality of health; and in access to health care and in health outcomes

Public health practitioners should look for differences:

within countries (between rich and poor) Gini Coefficient between / across countries (high, middle and low income countries) focus of RCSI public health curriculum

Horizontal Equity equal treatment because of equal need Vertical equity unequal treatment for unequal need, e.g.:
greater risk of TB in poor urban populations Greater risk of HIV in poor adolescent girls in Africa

Criteria for measuring health systems performance

Alma Ata 1978 and WHO 2000 Coverage Effectiveness + Efficiency Equity
what % of people access services use of proven interventions that bring maximum benefit for least cost of access to care based on need, not on ability to pay (fairness as important as effectiveness)

Responsiveness to service users needs Health of the Population morbidity and mortality data
Health system performance comparison: an agenda for policy, information and research. European Observatory on Health Systems and Policies. 2012
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Universal (Health) Coverage WHO 2010 unifying concept

A health care system which provides health care and financial protection to all its citizens
financial risk protection see slides and notes on financing improved access to health services see slides on Primary Health Care (PHC) principles. What are the barriers to access in your country: Financial Irelands two tier system Geographical rural versus urban (Health Policy lecture) Cultural / Gender barriers in. improved health outcomes Evidence Based Medicine / Health (EBM/EBH) Cost-effectiveness
Q: What is universal health coverage? 11 http://www.who.int/features/qa/universal_health_coverage/en/index.html

Spending on Health 2000-10

Statistics Country % of GDP spent on Health 2000 2010 3.9 8.8 6.1 3.1 13.4 6.1 5.7 4.3 11.4 9.2 4.4 17.6 10.2 6.0
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WHO Statistical Information System: http://www.who.int/gho/en/

Govt. Expenditure on Health (% of total) 2000 2010 67.5 70.4 75.1 59.0 43.2 90.8 51.3 71.1 71.1 69.2 55.5 48.2 95.2 60.8

Per capita Expend on Health ($) 2000 2010 497 2089 1561 125 4703 166 18 748 5257 4242 368 8233 583 74

Bahrain Canada Ireland Malaysia USA Cuba Zambia

Health performance indicators: 1990-2011 WHO Global Health Observatory:

http://www.who.int/whosis/en/index.html Statistics % Births by skilled attendant Country 90-99 05-12 Under 5 deaths DPT3 Vaccine (per 1000 live by 1 yr of age births) 1990 2011 1990 2011 Life expectancy at birth 1990 2011

Bahrain Canada Ireland Malaysia USA Cuba Zambia

98 98 100 81 98 100 42

97 99 100 99 99 100 47

21 8 9 17 11 13 193
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10 6 4 7 8 6 83

94 88 65 90 90 92 91

99 95 95 99 94 96 81

73 77 75 71 75 74 45

79 82 81 74 79 78 55